Claims Operations Manager

Claims Operations Manager, Health Plan

The Manager, Claims Operations is a critical role within the Claims Operations areas. We are hiring for two open manager roles; Medicaid and Commercial lines of business. Each role will oversee a large department of seasoned professionals with a wide array of skills. The ideal candidate will possess excellent communication and organizational ability. They will have a strong aptitude for technology and its impact on claims operations.

Job Summary

The Claims Operations Manager is responsible for managing claims operations to ensure efficient and accurate processing of claims. Oversees claims workflows, compliance, and team performance to support revenue cycle goals and optimize reimbursement processes. Responsible for planning, directing, and coordinating the day-to-day operations of the Claims Operations teams (including the claims reviewer team and the resolution team), ensuring that all metrics are achieved for quality, time, inventory, and aging for original claims and provider correspondence.

Essential Functions

• Monitors accurate reporting of claim key metrics including but not limited to claim turnaround times, denial rates, quality scores, claims over 30 and 45 days, customer service statistics, call tracking and correspondence inventories and turnaround, data entry numbers, and turnaround time.
• Set clear goals and objectives and use metrics to measure performance and hold staff accountable.
• Provide coaching to improve performance and hold regular development.
• Leads the claims operations team, including hiring, training, and performance management.
• Oversees the processing and submission of claims to ensure accuracy, timeliness, and compliance with payer requirements.
• Monitors claim metrics to identify trends, reduce denials, and improve revenue cycle performance.
• Implements and updates policies and procedures to align with regulatory standards and organizational goals.
• Collaborates with billing, coding, and clinical teams to address claims issues and resolve discrepancies.
• Manages relationships with insurance payers to streamline claims adjudication and reimbursement processes.
• Prepares and presents performance reports and improvement strategies to hospital leadership.

Qualifications

Skills For Success

Working Model Requirements

Remote Type

Hybrid

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$97,510.40 - $141,804.00 / Annual

Grade

EEO Statement

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and / or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.